PTSD and PNES: Prolonged exposure Treatment
Post traumatic stress disorder and PNES • What is PTSD? • What is the connection between PTSD and PNES? • Is there an effective treatment for PTSD? • Could this treatment help those diagnosed with PNES and PTSD?
What is Post traumatic Stress disorder? • Category: Anxiety disorder • Origin: Psychological Trauma as a result of a horrific, terrifying, life threatening, experience that shattered your sense of safety.
What can be traumatic? • Subjective: what is for one person, may not be… • Childhood abuse (sexual, physical, neglect) • Battlefield experiences • Being involved in a crime, accident, torture • Natural disaster • Witnessing the victimization of a loved one (e.g. mother, sibling). • Death of a loved one (e.g. child) • Being shunned by family and society
What is PTSD? • 1 Month Re-experience trauma • Avoidance of trauma reminders • Hyper vigilance • Negative mood and thoughts
Re-experiencing • Nightmares: of the event or unrelated • Flashbacks: Reliving the event as if it is happening now • Sudden memories triggered by a smell, sight, experience that is similar.
Avoidance • Efforts to forget: “Just forget it, push it away, move on.” • Numbing: Having difficulty feeling emotions, seeming cut off, shut down • Spotty memory: because so much energy is put into forgetting, forgetfulness spreads. • Avoid activities (the news, movies, going to places that are reminders or may be “dangerous” • Short-term solution but it makes it worse in the long run
Hyper-vigilance • Constant state of being alert and revved • Poor sleep • Startle response: jumpiness • Irritability, moodiness • Continuous scanning for danger, uneasiness • Fatigue and exhaustion as a result
Negative mood & thoughts • Cynicism: Jaded and negative view of others and life • Distrust of others and their intentions. Great care to not open yourself to getting hurt again • Negative self views: self-blame, guilt, weak, disabled, crazy.
PTSD and the brain • Trauma can transform the brain: • Limbic system (emotion center): fear and vigilance • Memory center is near limbic system: intense reaction to memories and forgetfulness of others • Prefrontal cortex: problem solving and emotion control • Left hemisphere: language dominant in most and could explain word finding problems and verbal memory weaknesses. • Increased Stress hormones: fight or flight response, increased glucose levels and heart rate, panicky feelings
Diagnostic criteria • 1 or > intrusive symptoms • 3 or > avoidance symptoms • 1 or > symptoms of hyper-vigilance • 3 or > negative changes in mood and thoughts • Symptoms intrude on daily life and become disabling.
Association between PNES and PTSD? • @75% PNES patients have a history of trauma. • @23-77% have a history of childhood sexual/physical abuse. • @25% fulfill criteria for post traumatic stress disorder (PTSD).
Dissociation • Why are PNES and PTSD connected? • When traumatized the brain uses extreme defense mechanisms. Dissociation • Intolerable experiences of near death and horror that can’t be escaped-the brain saves you by dissociating. • A dissociation pathway gets paved and future distress triggers this defense even when it is no longer needed.
PNES and PTSD • Patients with PNES/PTSD are different than other patients with PNES. • Epilepsy & Behavior 2013: Psychological trauma in patients with psychogenic nonepileptic seizures: Trauma characteristics and those who develop PTSD. Myers et. al. • Epilepsy & Behavior 2014: Cognitive differences between patients who have psychogenic nonepileptic seizures (PNESs) and posttraumatic stress disorder (PTSD) and patients who have PNESs without PTSD. Myers et. al.
How to treat PTSD • Intrusion: Those memories that intrude on you whenever THEY want: treatment teaches you to call forth those memories when you want. Retelling • Avoidance: the short-term solution becomes the problem. Do the opposite. • Negative mood and thoughts: therapy helps process and challenge these thoughts. (e.g. “I am weak because I have this,” “I blame myself for not fighting more”).
What does PET look like? • 1) education about common reactions to trauma • 2) Breathing retraining • 3) “Real Life” exposure to situations of activities avoided because they are reminders • 4) Repeated prolonged imaginal exposure (revisit the trauma by retelling the trauma memory in session.
What does PET look like? • Session 1: Overview of treatment program and rationale, trauma interview and breathing retraining. • Session 2: Common reactions to the trauma. “Real Life” hierarchy is constructed. • Session 3: Retelling your most disturbing trauma memory for the first time. • Session 4-9: trauma processing and hot spots. • Session 10: Discussion about your experiences with “real life” and imaginal exposure, progress and future.
Confrontation • Confronting the memory: • 1) Helps process the free-floating and intrusive memory. Putting into words brings the primitive memory to higher brain levels. • 2) You learn that thinking and remembering is not dangerous. • 3) You learn that relatively safe situations are not dangerous. • 4) Beliefs about self, others, and the world change for the better. • 5) You learn that habituation will help you in other situations to reduce anxiety.
Benefits and risks • Benefits: PET reduces PTSD symptoms and problems, depression and anxiety. • Risks: Discomfort and emotional distress especially when remembering trauma and confronting situations that were avoided before. • Therapists are certified therapists and some are also certified as supervisors. http://www.med.upenn.edu/ctsa/
Is PET effective? • 20 years of research has shown PET is an effective modality to treat PTSD. • Research studies have been conducted in the US, Israel, Japan, Australia, and Europe. • VA system has begun using PET with veterans and hundreds of mental health professionals from Vas have been trained.
IS PET effective for PNES? • PTSD is a very toxic condition that results in depression, substance abuse and potentially PNES. • At NEREG we are offering PET to our PNES/PTSD patients and results are very encouraging. • Design of research project on PET with PNES/PTSD is in the works at NEREG.
Other treatments • Stress inoculation treatment (SIT) • Cognitive processing therapy (CPT) • Eye movement desensitization and reprocessing (EMDR) • Medications: Zoloft and Paxil
Resources and contact • Psychogenic Non-epileptic Seizures: A Guide available on Amazon Chapter 3 • Website: www.nonepilepticseizures.com • Webinar on Psychogenic non-epileptic seizures on YouTube • Facebook: Psychological non epileptic seizures • Lmyers@epilepsygroup.com • www.epilepsyfree.comfor continuing education scholarships and funds for educational programs • PET article: http://articles.philly.com/2014-07-07/news/51110145_1_edna-foa-prolonged-exposure-therapy-ptsd